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Babies die from contaminated breast milk

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  • #76000
    Michael Wishart
    Participant

    Author:
    Michael Wishart

    Position:

    Organisation:

    State:
    NSW

    This tragedy in the US will be of interest to those with facilities with neonatal and maternity units.

    https://www.washingtonpost.com/health/2019/11/08/infants-died-after-being-fed-infected-breast-milk-hospital-kept-admitting-babies-anyway-lawsuit-alleges/?fbclidIwAR0TKIMpORcX0ptAQCFIdrTClcuMunqmihHdjjrW8Ay1PDDJG_rAR3cR_fY

    The regulation of breast milk ‘banks’ under the TGA will help to prevent this sort of issue within Australia, hopefully.

    Another reminder that basic cleaning and disinfection of equipment is never to be taken for granted.

    Cheers
    Michael

    Michael Wishart | Infection Control Coordinator, CICP-E

    St Vincent’s Private Hospital Northside | 627 Rode Road CHERMSIDE QLD 4032
    T +61 7 3326 3068 | F +61 7 3607 2226
    E michael.wishart@svha.org.au |
    W https://www.svphn.org.au

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    #76007
    Maree Sommerville
    Participant

    Author:
    Maree Sommerville

    Position:
    Senior Infection Control Nurse Consultant

    Organisation:
    VICNISS

    State:

    Hi Michael,
    I have some experience with the breast milk bank (BMB) in Victoria.
    The BMB was required to adhere strictly to the Victorian Human Tissue Act and the Victorian Food Act.
    I am sure the requirements for other states will be equally as stringent.
    I am unclear as to how the TGA should be involved in the regulation of a BMB if the state requirements are so stringent.
    Would you please elaborate?

    My reading of the article is that the contamination occurred in the nursery with an accepted practise (within that unit) of hand washing measuring equipment at the cot side rather than in the pasteurisation/bottling & dispensing process from the BMB.
    The take home message for me would be ensure an effective cleaning process is in place that meets food handling requirements.

    What I find worrying in the news item is that the source of pseudomonas is not clearly stated.
    The measuring device is washed by hand so does this imply there is contamination in the tap water or are the devices stored in such a way to facilitate contamination?
    Did they genotype the pseudomonas?
    Would such a long standing seemingly insidious practise of hand washing a measure be missed by our Infection Control teams?
    What other potentially dangerous but small practises are missed?
    Lots of questions with this one!!! I am sure the legal case will sort out these details.

    Meanwhile 3 babies did not make it home.
    It underlines the importance of good Infection Control practises.

    Maree

    Maree Sommerville
    Infection Control Consultant
    VICNISS Coordinating Centre
    Doherty Institute | Level 2
    792 Elizabeth St Melbourne VIC 3000
    T: +61 3 9342 9362 | F: +61 3 9342 9355 | http://www.vicniss.org.au

    This tragedy in the US will be of interest to those with facilities with neonatal and maternity units.

    https://www.washingtonpost.com/health/2019/11/08/infants-died-after-being-fed-infected-breast-milk-hospital-kept-admitting-babies-anyway-lawsuit-alleges/?fbclidIwAR0TKIMpORcX0ptAQCFIdrTClcuMunqmihHdjjrW8Ay1PDDJG_rAR3cR_fY

    The regulation of breast milk ‘banks’ under the TGA will help to prevent this sort of issue within Australia, hopefully.

    Another reminder that basic cleaning and disinfection of equipment is never to be taken for granted.

    Cheers
    Michael

    Michael Wishart | Infection Control Coordinator, CICP-E

    St Vincent’s Private Hospital Northside | 627 Rode Road CHERMSIDE QLD 4032
    T +61 7 3326 3068 | F +61 7 3607 2226
    E michael.wishart@svha.org.au |
    W https://www.svphn.org.au

    [cid:image001.jpg@01D46C86.4CDB6090]
    [2019 conference email signature]

    ______________________________________________________________________
    This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
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    #76009
    Michael Wishart
    Participant

    Author:
    Michael Wishart

    Position:

    Organisation:

    State:
    NSW

    Hi Martie

    Apologies for my assertion milk banks were now TGA regulated. That was based on a discussion some years ago, and I thought TGA had included donated human breast milk as a tissue under their regulations (see http://www1.health.gov.au/internet/main/Publishing.nsf/Content/D94D40B034E00B29CA257BF0001CAB31/$File/Donor%20Human%20Milk%20Banking%20in%20Australia%20paper%20(D14-1113484).docx ), but on further investigation I see that did not eventuate.

    As long as there are good standards, state-based or even facility-based, on which donor human breast milk is managed, I believe we are unlikely to see major cross infection.

    All of your questions are good ones, and further information about the actual incidents and investigations would be useful for us as infection prevention and control professionals, but, sadly, this may never make it into the public arena due to the litigation process.

    But, to me, it does reinforce, indeed, that basic cleaning and sanitisation of all items coming into contact with donor human breast milk, is so very critical.

    Cheers
    Michael

    Michael Wishart | Infection Control Coordinator, CICP-E

    St Vincent’s Private Hospital Northside | 627 Rode Road CHERMSIDE QLD 4032
    T +61 7 3326 3068 | F +61 7 3607 2226
    E michael.wishart@svha.org.au |
    W https://www.svphn.org.au

    [cid:image001.jpg@01D46C86.4CDB6090]
    [2019 conference email signature]

    Hi Michael,
    I have some experience with the breast milk bank (BMB) in Victoria.
    The BMB was required to adhere strictly to the Victorian Human Tissue Act and the Victorian Food Act.
    I am sure the requirements for other states will be equally as stringent.
    I am unclear as to how the TGA should be involved in the regulation of a BMB if the state requirements are so stringent.
    Would you please elaborate?

    My reading of the article is that the contamination occurred in the nursery with an accepted practise (within that unit) of hand washing measuring equipment at the cot side rather than in the pasteurisation/bottling & dispensing process from the BMB.
    The take home message for me would be ensure an effective cleaning process is in place that meets food handling requirements.

    What I find worrying in the news item is that the source of pseudomonas is not clearly stated.
    The measuring device is washed by hand so does this imply there is contamination in the tap water or are the devices stored in such a way to facilitate contamination?
    Did they genotype the pseudomonas?
    Would such a long standing seemingly insidious practise of hand washing a measure be missed by our Infection Control teams?
    What other potentially dangerous but small practises are missed?
    Lots of questions with this one!!! I am sure the legal case will sort out these details.

    Meanwhile 3 babies did not make it home.
    It underlines the importance of good Infection Control practises.

    Maree

    Maree Sommerville
    Infection Control Consultant
    VICNISS Coordinating Centre
    Doherty Institute | Level 2
    792 Elizabeth St Melbourne VIC 3000
    T: +61 3 9342 9362 | F: +61 3 9342 9355 | http://www.vicniss.org.au

    This tragedy in the US will be of interest to those with facilities with neonatal and maternity units.

    https://www.washingtonpost.com/health/2019/11/08/infants-died-after-being-fed-infected-breast-milk-hospital-kept-admitting-babies-anyway-lawsuit-alleges/?fbclidIwAR0TKIMpORcX0ptAQCFIdrTClcuMunqmihHdjjrW8Ay1PDDJG_rAR3cR_fY

    The regulation of breast milk ‘banks’ under the TGA will help to prevent this sort of issue within Australia, hopefully.

    Another reminder that basic cleaning and disinfection of equipment is never to be taken for granted.

    Cheers
    Michael

    Michael Wishart | Infection Control Coordinator, CICP-E

    St Vincent’s Private Hospital Northside | 627 Rode Road CHERMSIDE QLD 4032
    T +61 7 3326 3068 | F +61 7 3607 2226
    E michael.wishart@svha.org.au |
    W https://www.svphn.org.au

    [cid:image001.jpg@01D46C86.4CDB6090]
    [2019 conference email signature]

    ______________________________________________________________________
    This email and any attachments to it (the “Email”) is confidential and is for the use only of the intended recipient, and may not be duplicated or used by any other party without the express consent of the sender. If you are not the intended recipient of the Email, please notify the sender immediately by return email, delete the Email, and do not copy, print, retransmit, store or act in reliance on the Email. St Vincent’s Health Australia (“SVHA”) does not guarantee that the Email is free from errors, viruses or interference. Emails to and from SVHA or its related entities may be scanned and filtered in locations outside Australia.
    ________________________________
    MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

    The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

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    MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

    The use of trade/product/commercial brand names through the list is discouraged by ACIPC. If you wish to discuss specific reference to products or services by brand or commercial names, please do this outside the list.

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    MESSAGES POSTED TO THIS LIST ARE SOLELY THE OPINION OF THE AUTHOR, AND DO NOT REPRESENT THE OPINION OF ACIPC.

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